Hepatitis a Vaccine Promotion Using Facebook Ads to Reach At-Risk Groups

Abstract

Purpose

To evaluate using Facebook ads to promote hepatitis A vaccination to at-risk groups.

Design

This descriptive research study used Facebook ads and posts to deliver a social media health campaign.

Setting

The social networking site Facebook was used to target audiences in the United States.

Subjects

Adults in the United States with Facebook accounts were the general audience with at-risk audiences having interests or profile attributes in either LGBTQ or food service groups.

Measures

Facebook Ads Manager was used to determine impressions, engagement rates, link clicks, and cost per result of the ads. These metrics were measured to examine the use of Facebook ads and targeting audiences.

Analysis

Results

The campaign resulted in a reach of 53 422 users, 70 542 impressions, 457 unique link clicks (483 link clicks), an average cost per results of $0.92 USD, and the total amount spent of $445.68 USD. The amount spent was positively correlated with reach (r = .969), results (r = .994), cost per result (r = .841), and impressions (r =.957).

Conclusion

The social media health campaign was effective in reaching an audience about hepatitis A vaccination. Using interest groups was not more cost-effective than a using a general audience for link clicks.

Keywords

social media hepatitis A Facebook Ads health promotion men who have sex with men food service workers vaccines

In-Brief

With the current pandemic and social distancing recommendations, public health practitioners must look to social media and other no-contact ways of promoting health. This research helps direct health promotion practice in a social media platform and adds to the current research on health promotion of hepatitis A vaccine in social media which is lacking in publications.

This descriptive research study used Facebook ads and posts to deliver a social media health campaign to evaluate the impact of Facebook ads to promote hepatitis A vaccination to at-risk groups. The social networking site Facebook was used to target adults in the United States, with at-risk audiences having interests or profile attributes in either LGBTQ or food service groups.

The social media health campaign was cost-effective in reaching an audience about hepatitis A vaccination. Targeting audiences based on interest groups was not seen to be more cost-effective than using a general audience.

Purpose

Hepatitis A outbreaks since 2016 have been reported in 33 states resulting in more than 33, 615 cases, 20 595 (61%) hospitalizations, and 332 deaths reported as of August 2, 020.¹ The main forms of transmission are foodborne and person-to-person.² Outbreaks that occurred in 2013, 2016, and 2019 were due to foodborne infections while an increase in cases in 2017 and 2018 were due to person-to-person transmission.² The majority of those affected are adults since there is an effective vaccine that has been recommended in the childhood immunization schedule by the Advisory Committee on Immunization Practices (ACIP) since 2006. Due to its widespread use, Facebook has been adopted by many public health organizations as a tool for health promotion activities,³ but there is a paucity of published research on hepatitis A social media health campaigns. Jones and Salazar noted the viability of social media as a health promotion vehicle in HIV health promotion,⁴ but a study looking at drinking during pregnancy found Facebook to be limited in a one-way conversation that was not able to further address awareness of the health issue when negative comments were made.⁵ A small study⁶ noted success in using Facebook advertisements to target Chinese-Americans for hypertension awareness. The aim of this study was to evaluate the reach of Facebook ads for health promotion and awareness of hepatitis A vaccination to at-risk groups.

Methods

Design

The AMU & APU Public Health Facebook page was used to disseminate information for the online health campaign titled Stick It To Hep A. This campaign “was part of a larger research study that consisted of 11 social marketing health campaigns”⁷ which was approved by the American Public University System Institution Review Board under grant 2018-201. All media included the hashtag #StickItToHepA for digital branding and tracking.

Five Facebook Ads were created that varied in images and text, but all included a link to the Centers for Disease Control and Prevention website on hepatitis A (https://www.cdc.gov/hepatitis/hav/) as the call to action. Social Learning Theory posits that individuals must be made to evaluate their individual vulnerability and susceptibility to diseases that have outcomes that are severe to be motivated to change their behavior.⁸ Using this theory in combination with the guidance provided by the Centers for Disease Control and Prevention regarding health communication in social marketing,⁹ a set of advertisements was designed with targeted messaging set to display to specific target audiences on Facebook. Men who have sex with men (MSM) have been identified as a high-risk group for hepatitis A and the ACIP has recommended hepatitis A vaccination for this group since 1996.¹⁰ Food service workers (FSW) can be a source of hepatitis A transmission and outbreaks if they are infected and use improper sanitation while preparing food for the public.¹¹ Therefore, 2 advertisements were tailored to FSW, 2 advertisements were tailored to MSM, and 1 ad for a general audience (Figure 1). The general audience and MSM ads started on October 4, 2019 and ran for 7 days (except for MSM1 ad which was prematurely pulled due to negative comments). The FSW ads began running on October 30, 2019 and ran for 8 days. The budget for the entire campaign was set at $500. The budget was optimized across ad sets and the lowest bid strategy was used to obtain results (link clicks). A maximum daily limit of $100 was set.

Figure 1.

Facebook advertisements for #StickItToHepA health campaign: food service workers-FSW1 (left), men who have sex with men-MSM1 (middle), and MSM2 and general audience (right).

Sample

There were 3 target audiences used for Facebook ads: (1) general audience, (2) MSM, and (3) FSW. The audience selection was “fairly broad” according to Facebook for all target audiences with a potential reach of 230 million for the general audience, 35 million for the FSW ads, and 12 million for the MSM ads. However, this is not an estimate of the total users who may see the ad. An estimate of how many users may see the ad is dependent on budget and performance of ad. Due to the campaign budget being optimized across ad sets, the true estimate of how many users could view the ad is not available.

Using Facebook Ads Manager, criteria were selected based on demographics and special interests. The general audience included any gender, 18 years and older, and located in the United States (language filters were not used). The MSM audience included males, 18 years and older, and located in the United States, with special interests: Gay Life, Gay Love, Gay Pride, Gay Times, Gay Times Magazine, Gay-Friendly, LGBT Community, and LGBTQ Nation. The FSW audience was any gender, 18 years and older, and located in the United States, with work or interests: Food & Restaurant Page Admins, Employers: Food Industry, Industry: Food and Restaurants, Job Title: Food and Beverage Server and Food Server, Additional Interests: Food Industry and Food Safety, Interest: Food Trucks and Fast Food Restaurants. No other exclusion criteria were used to filter audiences for ads.

Measures

Facebook Ads Manager was used to determine the success of ads. This study included metrics generally used in social media studies^5,7 including reach (number of people who saw the ad at least once), impressions (number of times ads were seen on a screen), results (number of times ad achieved a given outcome), link clicks (number of times a user clicked on the link within the ad), and cost per result (average cost per result of ad where result is defined as the link click to learn more). Ads distribution complied with Facebook policies, and users voluntarily clicked on the Facebook Ads to learn more which directed them to a public health website. No identifying information or user profiles were collected in this study, nor are available in Facebook Ads Manager. All data are aggregated and remain anonymous to the Facebook Ads account owner.

Analysis

Quantitative data were analyzed using descriptive statistics, and the Pearson correlation coefficient analysis was used to determine if the amount spent on each ad had any correlation with reach, results, cost per result, or impressions. Cost per result was used to compare ad sets and determine cost-effectiveness using result (link clicks) as the outcome.

Results

The ads resulted in a total reach of 53 422 users, 70 542 impressions, 457 unique clicks, and an average cost per result of $0.92. The amount spent ($445.68) was positively correlated with reach (r = .969, P = .006), results (r = .994, P < .001), impressions (r = .957, P = .01), and cost per result (r = .841, P = .07), although cost per result was not statistically significant.

The ads and ad sets had similar results when looking at cost per click ($0.90 – $0.99, except for MSMl which was only run over 1 day). However, when looking at all other metrics, the FSW1 ad had the best performance with the highest reach, impressions, and total budget spent. Despite having the same audience demographics and length of time ad was run, the FSW1 and FSW2 ads had the most difference between them in reach where FSW1 (18 247) was more than FSW2 (8766) as well as the largest difference in all other metrics (apart from MSM1 ad) (Table 1). The FSW1 ad also had the most user engagement of all ads with 23 reactions, 1 comment, and 12 shares.

Table 1.

Facebook advertisement metrics for the #StickItToHepA campaign based on target audience: general audience, men who have sex with men (MSM), and food service workers (FSW).

Ad Name	Duration (Days)	Reach	Impressions	Link clicks	Total spent (USD$)	Cost per result (USD$)
General audience	7	14 496	17 975	132	128.21	.97
MSM1	1^a	1730	1881	38	13.75	.36
MSM2	7	11 404	14 686	110	108.04	.98
FSW1	8	18 247	24 440	146	144.47	.99
FSW2	8	8766	11 560	57	51.21	.90

Abbreviation: MSM, men who have sex with men; FSW, food service workers.

^aDid not run for the entire duration, inactivated due to negative interactions.

The frequency of the ads was similar among the ads except for MSM1 due to its short run time (MSM1 = 1.09, MSM2 = 1.29, FSW1 = 1.34, FSW2 = 1.32, General audience = 1.24). Frequency is an estimation of the average number of times each user sees the ad and is used to determine if the ad may suffer from viewer fatigue. A frequency of less than 2 indicates that on average a user saw the ad less than 2 times indicating there was no fatigue associated with the run time of the ads.

Cost-effectiveness of each ad using the cost per result metric and link clicks as the outcome showed similar cost-effectiveness among ads (Table 1). The budget optimization across ad sets may contribute to the cost-effectiveness of each ad as dollars spent are changed dynamically to optimize results (link clicks).

Discussion

Overall, the social media campaign was effective in reaching an audience and generating link clicks to learn more with an average cost per result of $0.92. There were limited results demonstrating that using more tailored audiences within the Facebook advertising framework was more cost-effective than using a general audience. However, men were reached less when women were included in the audience. For the general audience ad, 10 040 women were reached vs only 4376 men. For the FSW ads, 18 511 women were reached vs 7296 men. For the MSM ads, only men were included in the audience and a total of 12 948 men were reached. This demonstrates that men in general may be harder to reach for health promotion on social media as was also seen in previous studies,⁶ but this can vary based on topic and ad content.

While Cost per Result is a metric often used as it shows a person taking action (i.e., clicking on link), albeit a low-level engagement, reach may also be important in health promotion as the visual stimulus of seeing the ad may encourage users to take action off of social media. The ads reach varied, but the FSW1 ad had the highest reach and highest link clicks showing that using special interests may be more successful than a general audience in reaching a population. However, all other targeted ads performed lower than the general audience in reach and link clicks. Additionally, the FSW1 had the largest portion of the budget spent. Because the budget was optimized for the campaign, the amount spent on each ad and ad set varied as to give more of the budget to the better preforming ads. Since FSW1 had the largest portion of the budget allocated to it, it means it was a better preforming ad which could be based on both audience targeting and ad visualization as FSW1 and FSW2 had the same target audience and FSW1 and the general audience ad had the same message. Therefore, looking at metrics beyond cost per result may lead to improved messaging via Facebook advertisements.

Some ads generated negative comments which deterred from the main message of the ads (5 negative comments, 1 positive comment, and 1 neutral comment). Most negative comments were on the MSM1 ad which was subsequently canceled after 1 day. Previous research has found when an interest group is targeted via Facebook Ads Manager, the potential reach includes not only those who have positive views of that interest, but also those who have negative views of that interest.¹² On 2 ads, comments were made that questioned the safety and effectiveness of vaccines. Research has shown that negative comments can influence the perception of subsequent visitors⁵ and negative comments on a health promotion effort can render that effort ineffective.¹³ The negative comment about vaccine safety and efficacy was replied to further conversation on the issue. No subsequent comments were made.

Limitations

This study’s limitations include accessing only those with social media accounts during the specified time frame, October 04, 2019 to November 7, 2019. Also, only link clicks were used to show if action was taken after seeing the ad. It is unknown if people used resources outside the ad or if the ads contributed to higher interest in vaccination.

Another limitation in sampling may be due to language barriers. Although language was not used to filter the audience, the ad was written in English. Facebook automatically translates language for users who choose to have posts translated to their language of choice in their profile settings, but it cannot be ruled out that a language barrier may have contributed to lower engagement with users whose preferred language is not English.

The budget constraints limited this study to be small in scale. Facebook allows the ad manager to choose how to spend the budget and this may affect how well the campaign does. For this study, lowest bid strategy was used to deliver ads. While this can constrain the delivery of ads, increasing the target population can allow for increased delivery of ads. In this study, there was a large target population for each of the groups (in the millions) which allowed for an increase in ad delivery, but the lowest cost bid strategy may have limited results.

So What? Implications for Health Promotion Practitioners and Researchers

What is already known on this topic?

Prior research indicates that using social media for health promotion is successful because its ubiquitous use overcomes many socioeconomic barriers that prevent traditional health promotion efforts for hard-to-reach populations. Facebook provides a large potential audience for health promotion campaigns.

What does this article add?

This study examined two populations that are at-risk of transmitting hepatitis A: MSM and food service workers. The article adds to social media research on specific audiences for a hepatitis A health promotion campaign using Facebook advertising audience targeting tools to increase engagement rates, but also notes the potential for negative audience interactions.

What are the implications for health promotion practice or research?

Footnotes

Author Contributions

Pamela SchwartzMade a substantial contribution to the concept or design of the work; or acquisition, analysis or interpretation of dataDrafted the article or revised it critically for important intellectual contentParticipated sufficiently in the work to take public responsibility for appropriate portions of the content.Dr Jennifer SedilloMade a substantial contribution to the concept or design of the work; or acquisition, analysis or interpretation of dataDrafted the article or revised it critically for important intellectual contentParticipated sufficiently in the work to take public responsibility for appropriate portions of the content.Dr Jessica SappMade a substantial contribution to the concept or design of the work; or acquisition, analysis or interpretation of dataDrafted the article or revised it critically for important intellectual contentApproved the version to be publishedParticipated sufficiently in the work to take public responsibility for appropriate portions of the content.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The original research project “Establishing an Online Public Health Community Service Model for a Fully Online University: A Pilot Study to Determine the Effectiveness of Digital Volunteering” was funded by grants from the American Public University System (APUS) and was reviewed and approved by the APUS Institutional Review Board under tracking number 2018-201. Principal Investigator: Jessica L.C. Sapp, DrPH, MPH

ORCID iDs

Jennifer L. Sedillo

Jessica L.C. Sapp

References

Centers for Disease Control and Prevention (CDC) . Widespread Person-To-Person Outbreaks of Hepatitis A across the United States. https://www.cdc.gov/hepatitis/outbreaks/2017March-HepatitisA.htm.

Centers for Disease Control and Prevention . Hepatitis A Outbreaks in the United States. https://www.cdc.gov/hepatitis/outbreaks/hepatitisaoutbreaks.htm.

Kite

Foley

Grunseit

Freeman

. Please like me: facebook and public health communication. PLoS One;11(9); 2016:e0162765. doi:10.1371/journal.pone.0162765.

Jones

Salazar

. A review of HIV prevention studies that use social networking sites: implications for recruitment, health promotion campaigns, and efficacy trials. AIDS Behav. 2016;20(11):2772-2781. doi:10.1007/s10461-016-1342-9.

Parackal

Eusebius

Mather

. The use of facebook advertising for communicating public health messages: a campaign against drinking during pregnancy in New Zealand. JMIR Public Health Surveill. 2017;3(3):e49. doi:10.2196/publichealth.7032.

Dunn

Woo

. Facebook recruitment of Chinese-speaking participants for hypertension education. J Am Soc Hypertens. 2018;12(9):690-692. doi:10.1016/j.jash.2018.06.017.

Polak

Sapp

JLC

Sedillo

. Using facebook ads to promote blood pressure checks among African Americans in the United States: a descriptive study. J Health Soc Sci. 2020;5(3):343-354. doi:10.19204/2020/sngf6.

AuYong

H-N

Yeoh

G-G

. The emerging web 2.0 social media as a tool to develop engaged audiences for behaviour change in health promotion: an overview. SHS Web of Conferences. 2017;33:00074. doi:10.1051/shsconf/20173300074.

Centers for Disease Control and Prevention . Health Communication Basics. Updated May 10, 2011. https://www.cdc.gov/healthcommunication/healthbasics/index.html. Accessed on April 01, 2021.

10.

Centers for Disease Control and Prevention . Men Who Have Sex with Men and Viral Hepatitis. Updated August 24, 2020 https://www.cdc.gov/hepatitis/populations/msm.htm#:∼:text=CDC%20and%20the%20Advisory%20Committee,vaccine%20using%20a%20recommended%20schedule. Accessed March 15, 2021.

11.

U.S. Food and Drug Administration (FDA) . Hepatitis A Virus (HAV). Updated March 29, 2019 https://www.fda.gov/food/foodborne-pathogens/hepatitis-virus-hav. Accessed April 01, 2021.

12.

Mitchell

Lee

J-Y

Stephenson

. How best to obtain valid, verifiable data online from male couples? lessons learned from an ehealth HIV prevention intervention for HIV-negative male couples. JMIR Public Health Surveill. 2016;2(2):e152. doi:10.2196/publichealth.6392.

13.

Shi

Messaris

Cappella

. Effects of online comments on smokers’ perception of antismoking public service announcements. J Comput-Mediat Commun. 2014;19(4):975-990. doi:10.1111/jcc4.12057.